session 7: implementation solutions and approaches to ... · inhambane vilankulo 1,874 12,428 15%...
TRANSCRIPT
Session 7: Implementation Solutions and
Approaches to Reach Epidemic Control among Adult Men
2
Strategic Approaches to Reduce HIV Morbidity and Mortality Among Men
Setting the Scene
HIV Care and Treatment Cascade for Men
Ministry Male Engagement Strategy
Preventing New Infections Among Adolescents & Young Men
VMMC
Increasing ART Coverage Among Men
Strengthening Case Identification
Improving Treatment Initiation
Enhanced Support for Adherence & Retention
3
Men as Proportion of Total Persons on Treatment in Mozambique
In 2014, large-scale retrospective evaluation showed a significant decrease in the proportion of newly enrolled on treatment that were men between 2004 and 2013
2004 2013
0.3% 22%
57% 51%
45% 22%
(Auld et all, 2014)
4
Men Continue to Lag Behind Women in Treatment Cascade Achievements
PEPFAR/MER Data: DevResults (2015 – 2016)/DATIM (2017-2018)
5
Overall ART Coverage is also Lower Among Men than Women In all Provinces
Largest gaps in coverage are in Gaza and Inhambane, locations with high rates of migrant work to S. Africa PLHIV: IMASIDA 2015, Census 2017, Spectrum V5.6;
TX_Curr: PEPFAR/MER (DATIM)
CaboDelgado
Gaza Inhambane Manica MaputoCidade
MaputoProvíncia
Nampula Niassa Sofala Tete Zambézia
Female Coverage 34% 67% 51% 63% 120% 38% 44% 33% 53% 71% 42%
Male Coverage 22% 39% 24% 44% 88% 22% 32% 20% 33% 52% 25%
0%
20%
40%
60%
80%
100%
120%
140%
Co
vera
ge
National Coverage among Men: 33%
National Coverage among Women: 52%
6
Highest Unmet Need for Men found in Zambezia and Maputo Province
PLHIV: IMASIDA 2015, Census 2017, Spectrum V5.6; TX_Curr: PEPFAR/MER (DATIM)
22%
39%
24%
44%
88%
22%
32%
20%
33%
52%
25%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
-
20,000
40,000
60,000
80,000
100,000
120,000
140,000
CaboDelgado
Gaza Inhambane Manica MaputoCidade
MaputoProvíncia
Nampula Niassa Sofala Tete Zambézia
Co
vera
ge
# o
f P
LHIV
Number of Men on Treatment, Unmet Need, and Coverage by Province, FY17
TX_CURR Unmet Need Coverage
7
Ministry and Civil Society Working Together To Improve Engagement of Males in Treatment
November 2016
Joint stakeholder meeting to understand
successes and challenges in each
province
March 2017
Male engagement TWG started to
develop comprehensive
strategy to improving male engagement
December 2017
National stakeholder meeting to review Male Engagement
Strategy and incorporate best
practices
March 2018
National launch of Male Engagement Strategy (at HIV Program Annual
Meeting)
June-Dec 2018
Roll-out of strategy to priority districts
National Male Engagement Strategy
8
Core Components of MISAU Male Engagement Package
Promotion of friendly services for men in health facilities and in the workplace
Promotion of social norms that may facilitate the use of health services
Promotion of engagement of men as a partner in the care of their wives/children (family care approach)
Promotion of communication and advocacy to increase knowledge and importance of the use of health services by men
Strengthening monitoring and evaluation of the impact of male engagement interventions on health care and community
9
Targeting Male Engagement Strategy to Areas of Highest Need
50% of Unmet Need for Men is Found in 20 Districts
Targets for TX_NEW are most aggressive in these 20 districts
Province District Name
TX_CURR
(FY17)
PLHIV
(FY17)
ART
Coverage
Unmet
Need
% of Unmet
Need
Maputo Província Cidade Da Matola 14,503 90,122 16% 75,619 13%
Sofala Cidade Da Beira 9,964 37,943 26% 27,979 5%
Zambézia Cidade De Quelimane 8,833 27,951 32% 19,118 3%
Manica Cidade De Chimoio 7,511 19,516 38% 12,005 2%
Nampula Cidade De Nampula 6,380 17,958 36% 11,578 2%
Zambézia Nicoadala 2,723 14,218 19% 11,495 2%
Cabo Delgado Mueda 2,163 13,345 16% 11,182 2%
Maputo Província Marracuene 3,321 14,393 23% 11,072 2%
Inhambane Vilankulo 1,874 12,428 15% 10,554 2%
Maputo Província Boane 3,313 13,846 24% 10,533 2%
Zambézia Mocuba 4,098 14,311 29% 10,213 2%
Zambézia Namacurra 3,142 13,111 24% 9,969 2%
Zambézia Pebane 3,476 13,229 26% 9,753 2%
Maputo Cidade Kamubukwana 4,427 13,343 33% 8,916 2%
Gaza Chokwe 7,722 16,513 47% 8,791 2%
Gaza Bilene 3,579 11,012 32% 7,433 1%
Gaza Cidade De Xai-Xai 4,651 11,856 39% 7,205 1%
Zambézia Milange 2,589 9,636 27% 7,047 1%
Zambézia Maganja Da Costa 1,966 8,956 22% 6,990 1%
Cabo Delgado Muidumbe 1,321 7,861 17% 6,540 1%
10
Targeting Male Engagement Strategy to Areas of Highest Need
50% of Unmet Need for Men is Found in 20 Districts
Province District Name
TX_CURR
(FY17)
PLHIV
(FY17)
ART
Coverage
Unmet
Need
% of Unmet
Need
Maputo Província Cidade Da Matola 14,503 90,122 16% 75,619 13%
Sofala Cidade Da Beira 9,964 37,943 26% 27,979 5%
Zambézia Cidade De Quelimane 8,833 27,951 32% 19,118 3%
Manica Cidade De Chimoio 7,511 19,516 38% 12,005 2%
Nampula Cidade De Nampula 6,380 17,958 36% 11,578 2%
Zambézia Nicoadala 2,723 14,218 19% 11,495 2%
Cabo Delgado Mueda 2,163 13,345 16% 11,182 2%
Maputo Província Marracuene 3,321 14,393 23% 11,072 2%
Inhambane Vilankulo 1,874 12,428 15% 10,554 2%
Maputo Província Boane 3,313 13,846 24% 10,533 2%
Zambézia Mocuba 4,098 14,311 29% 10,213 2%
Zambézia Namacurra 3,142 13,111 24% 9,969 2%
Zambézia Pebane 3,476 13,229 26% 9,753 2%
Maputo Cidade Kamubukwana 4,427 13,343 33% 8,916 2%
Gaza Chokwe 7,722 16,513 47% 8,791 2%
Gaza Bilene 3,579 11,012 32% 7,433 1%
Gaza Cidade De Xai-Xai 4,651 11,856 39% 7,205 1%
Zambézia Milange 2,589 9,636 27% 7,047 1%
Zambézia Maganja Da Costa 1,966 8,956 22% 6,990 1%
Cabo Delgado Muidumbe 1,321 7,861 17% 6,540 1%
Highest Burden Districts Included
Among 59 Districts
Prioritized for Male
Engagement in FY18-FY19
11
ART Coverage by Age Among Males
Adult men (Age 25-49) make up 69% of the Unmet Need ART Coverage is lowest in adolescent men (Age 15-24)
Data source: Spectrum v5.63, FY17 TX_CURR Program results are imputed for sites missing age bands (non-EPTS sites)
29%
37% 40%
23% 19%
34%
58%
0%
10%
20%
30%
40%
50%
60%
70%
-
50,000
100,000
150,000
200,000
250,000
300,000
350,000
400,000
450,000
<1 1-9 10-14 15-19 20-24 25-49 50+
Co
vera
ge
PLH
IV
Current on Treatment, Unmet Need, and Coverage by Age among Males, FY17
TX_CURR Unmet Need Coverage %
12
Strategic Approaches to Reduce HIV Morbidity and Mortality Among Men
Adolescent Men (Focus: Age 15-24)
Preventing New Infections:
- Continued VMMC Scale-up
- Community Outreach
- Condoms
Adult Men (Focus: Age 25-49)
Improving ART Coverage:
- Early Case Detection
- Improving Linkage and Treatment Initiation
- Strengthening Retention and Adherence
Implementation Solutions and Approaches to Prevent Infections among Adult Men
- VMMC -
14
Impact of PEPFAR-Supported VMMC Program Notable in Surveillance Data Coverage
9.20%
20.10%
47.50%
68.60% 71.10%
23.41%
31.00%
39.59%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
2009 2010 2011 2012 2013 2014 2015
% M
en a
ged
15
-49
wh
o a
re c
ircu
mci
sed
Data Collection Year
Zambezia Tete Manica
Sofala Gaza Maputo
Maputo City Weighted Average
INSIDA DHS IMASIDA
Start of PEPFAR-Supported VMMC
Program
PROJECT SOAR
15
COP Planning Decision Tree: VMMC Coverage
Problem Diagnosis
Strategic Objective
Approach
Many districts <80%
coverage among 20-29 year old men
Problem Statement/Indicator
New strategies
needed for districts with
higher coverage and lower growth
Monitoring and Partner Management
Scale up most effective program elements
16
Encouraging Results From the Caia Campaign
November/December 2017
District Health facility Type of site VMMCs Completed, November - December 2016
VMMCs Completed, November - December 2017
Caia
CS Caia Fixed 540 605
CS Murraca Mobile N/A 196
CS Sena Temporary N/A 375
Total 540 1176
120% Increase in circumcisions compared to prior year, 20% of district annual target
achieved in 5 weeks
• Future campaigns to have: • Sites better prepared to host upcoming
campaigns • Stronger involvement of local leadership
in demand creation
17
Scale up plan for campaigns
12 campaigns in 24 districts anticipated to make up 21% of annual CDC
target
1176
10000
23288 23112
0
5000
10000
15000
20000
25000
Q1 Q2 Q3 Q4
COP17 Quarters
#of MC
18
COP Planning Decision Tree: VMMC Coverage
Problem Diagnosis
Strategic Objective
Approach
Many districts <80%
coverage among 20-29 year old men
Campaigns
Problem Statement/Indicator
New strategies
needed for districts with
higher coverage and lower growth
Monitoring and Partner Management
# of campaigns & # of temp. sites/quarter
Scale up most effective program elements
19
COP Planning Decision Tree: VMMC Coverage
Problem Diagnosis
Strategic Objective
Approach
Many districts <80%
coverage among 20-29 year old men
Campaigns
Problem Statement/Indicator
New strategies
needed for districts with
higher coverage and lower growth
Monitoring and Partner Management
# of campaigns & # of temp. sites/quarter
Scale up most effective program elements
Implement additional demand creation
• Non-coercive incentives
• Grassroots soccer
• Targeting informal markets
• Active collaboration with
civil society.
• Recruitment of additional
CBOs
20
COP18 VMMC Targets Follow Trend of Aggressive Growth
86% of annual target. With more aggressive interventions, target
achievable
21
Targeting for VMMC Saturation
*Provincial coverage estimates based on SOAR data using weighted average of districts with VMMC targets (non-targeted districts excluded)
Province FY16
Achievement FY17
Achievement COP17 Target COP18 Target
Maputo City 79 86 87
92
Maputo Province 65 71 77
85
Gaza 42 56 76
84
Manica 17 31 49
66
Sofala 38 58 72
89
Tete 9 31 53 74
Zambezia 52 65 77 86
22
Trend of the VMMC National Program by Province
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
2010 2011 2012 2013 2014 2015 2016 2017 COP17Target
COP18Target
An
nu
al V
MM
Cs
Year
Gaza
Manica
Maputo Cidade
Maputo Provincia
Sofala
Tete
Zambezia
DOD
23
JHPIEGO Performance Lags Behind Other Partners
Province Partner FY17 Achievement
% FY17 Target Achieved
FY18 Q1 Achievement
FY18 Seasonal Estimate
FY18 Estimated Achievement
Military Jhpiego 24,289 83% 5,397 24,238 88%
Gaza Jhpiego 26,745 91% 5,552 24,934 61%
Maputo City Jhpiego 12,338 65% 1,627 7,307 474%
Manica JSI/AIDSFree 51,482 112% 16,440 73,832 107%
Maputo Province
Jhpiego 15,383 73% 3,225 14,483 60%
Sofala Jhpiego 44,016 43% 9,707 43,594 73%
Tete JSI/AIDSFree 49,154 100% 12,065 54,184 106%
Zambezia ICAP 47,255 86% 11,668 52,401 109%
Zambezia Jhpiego 43,488 57% 12,013 53,950 66%
24
High Saturation in JHPIEGO-Supported Provinces
*Provincial coverage estimates based on SOAR data using weighted average of districts with VMMC targets (non-targeted districts excluded)
Province Partner FY16
Achievement FY17
Achievement COP17 Target COP18 Target
Maputo City JHPIEGO 79 86 87 92
Maputo Province JHPIEGO 65 71 77 85
Gaza JHPIEGO 42 56 76 84
Manica AIDS FREE 17 31 49 66
Sofala JHPIEGO 38 58 72 89
Tete AIDS FREE 9 31 53 74
Zambezia JHPIEGO/ICAP 52 65 77 86
25
JHPIEGO Corrective Action Plan
• Scale up of:
• VMMC campaigns
• Temporary sites (Increased from 20 to 66)
• Public-private partnerships to cover large companies and informal markets
• Demand creation
• Incorporation of selected practices from other partners
• Single VMMC commodity partner
• Support from central demand creation partner
• Site optimization tool
• Enhanced monitoring
• Target redistribution
26
JHPIEGO Corrective Action Plan Tool
Weekly Targets
Performance towards target
District Capacity
27
JHPIEGO Corrective Action Plan Tool
Action Plan Strategies by
district
Targets by
Strategy
Timeline including
planning and implementation
28
Target Redistribution from CDC JHPIEGO to ICAP
• ICAP to cover 6 additional underperforming districts
• Transition starts immediately
• Joint work plan in preparation: CDC, ICAP, Jhpiego and MOH
Partner COP17 Total targets COP18 Total targets
AIDSFREE 120,470 128,549
ICAP 51,368 70,966
JHPIEGO 204,924 197,129
JHPIEGO FADM 27,527 34,343
Grand Total 404,289 430,986
29
COP Planning Decision Tree: VMMC Coverage
Problem Diagnosis
Strategic Objective
Approach
Many districts <80%
coverage among 20-29 year old men
Campaigns
Problem Statement/Indicator
New strategies
needed for districts with
higher coverage and lower growth
Monitoring and Partner Management
# of campaigns & # of temp. sites/quarter
Scale up most effective program elements
Implement additional demand creation
Enhanced monitoring,
# of MCs/Week by district
Target redistribution
- Incentives - Grassroots
Soccer - Community DC
Improving Early Case Identification Among Men
31
Growth in case detection among
males during FY17 was due to
programmatic shifts that included strengthening PITC
in high-yield sectors and
expansion of high-yield community-based modalities
such as index case testing.
0
2000
4000
6000
8000
10000
12000
CHASS ICAP ARIEL CCS EGPAF FGH JHPIEGO
Male positive HTC results by partner FY17 Q1-Q4
FY17 Q1
FY17 Q2
FY17 Q3
FY17 Q4
Most Partners Show Increases in Identification of Positive Men
32
Decision Tree: Case Identification for Adult Men
Problem Diagnosis Strategic Objective
Approach
Low case identification
for men
Increase case identification of
HIV+ men
Problem Statement/Indicator
Men not seeking health care @
facilities
Providers not screening men
sufficiently for HIV risk within high-
yield sectors
Providers not following-up
sufficiently with women for index case or partner
testing
Monitoring and Partner Management
33
Key Policy Achievements for Continued Performance in HTS
• Leadership from MOH for expansion of index case testing as effective intervention.
• Design of new HTS registers to document all eligible sexual partners and biological children of PLHIV for subsequent follow-up.
Index Case Testing
• Development of National Male Engagement Strategy to promote male accompaniment and male testing during first ANC and to guide targeted community-based testing efforts.
ANC Partner Testing
• Development of National Guidelines for Differentiated Service Delivery Models for HTS to prioritize efficient case identification in high-yield sectors.
PICT
All included as core components in the National Strategy for Male Engagement
34
Decision Tree: Case Identification for Adult Men
Problem Diagnosis Strategic Objective
Approach
Low case identification
for men
Increase case identification of
HIV+ men
Problem Statement/Indicator
Men not seeking health care @
facilities
Providers not screening men
sufficiently for HIV risk within high-
yield sectors
Providers not following-up
sufficiently with women for index case or partner
testing
Index coverage proxy by district; MER & New HTC
Registers
Monitoring and Partner Management
Scale-up Community-Based Index Case Testing
35
5.0%
17.3%
28.9%
23.4%
2.1% 4.3%
9.0% 9.1%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
15-19 yrs 20-24 yrs 25-49 yrs 50+ yrs
Mal
e T
est
ing
Yie
ld
Male Yield by Modality and by Age Group, FY17 & FY18 Q1
Yield - Index
Yield TB
Yield Other PITC
Yield Other Comm.
Yield VMMC
Strategic Shift to Community Index Case Testing is Working
Average yield among adult men from index
case testing in FY17 was higher than the target
set (15% overall). In FY19 the program will continue a shift away
from lower-yield community-based testing strategies.
Index case testing yield 3x other community testing yield
36
Setting Index Case Testing Coverage Benchmarks
Benchmark for Index Case Testing coverage used to identify areas for further growth
Coverage proxy:
# Male Adult Index TST conducted
÷ # Female Adult Non-Index POS
= Index Testing
Coverage Proxy
37 PTARGET ASSUMPTIONS MAY NOT BE EXACTLY AS STATED
Targeting Scale-Up of Best Index Case Testing Practices in COP18
Province
FY17 Adult
Index TST
Achieved
FY17 Adult
Index
Yield
FY19 Adult
Index TST
Target
% Increase
Index TST
FY18
Community
Index Case
Testing Partner
FY19 Community
Index Testing
Partner
Cabo Delgado 10,700 4.9% 12,458 16% ARIEL ARIEL
Cidade De Maputo 20,469 28.0% 49,126 140% Jhpiego Jhpiego
Gaza 38,931 9.8% 45,579 17% EGPAF EGPAF
Inhambane 2,073 15.9% 8,199 295% N’weti N’weti
Manica 3,158 29.5% 26,304 733% CHASS CHASS
Maputo 39,161 22.3% 87,740 124% Jhpiego/ARIEL Jhpiego/ARIEL
Nampula 640 25.9% 17,363 2,613% ICAP/Ophavela Jhpiego
Niassa 863 37.0% 7,730 796% CHASS CHASS
Sofala 6,803 37.0% 22,081 225% CHASS CHASS
Tete 3,895 22.4% 8,734 124% CHASS CHASS
Zambezia 8,424 29.5% 59,778 610%
FGH/CHASS/
ICAP/World
Vision
FGH/CHASS/
Jhpiego/World
Vision
Grand Total 135,117 262.2% 345,091 155%
Targets reflects scale up: ratio of index cases to seeds from 0.75 to 1.5
COP18 target assumes improved fidelity, yield of at least 25%
Substitution of lower
performing partners for partner with
demonstrated ability to
implement at scale
38
Decision Tree: Case Identification for Adult Men
Problem Diagnosis Strategic Objective
Approach
Low case identification
for men
Increase case identification of
HIV+ men
Problem Statement/Indicator
Men not seeking health care @
facilities
Providers not screening men
sufficiently for HIV risk within high-
yield sectors
Providers not following-up
sufficiently with women for index case or partner
testing
Index coverage proxy by district; MER & New HTC
Registers
Monitoring and Partner Management
Sector-specific testing coverage by site; MER &
New HTC Registers
Optimize Facility-Based Testing (PICT & ANC
Partner Testing)
Scale-up Community-Based Index Case Testing
39
Intervention Package for Effective PITC Optimization
Secure district-
level MOH buy-in
Through regular engagement and joint supervision activities
Reinforce index
contact eligibility screening
Through training on enhanced post-test
counselling and referrals
Provide regular
logistical support for operations
Monitoring of testing coverage and yield
Through facilitated data review sessions
with providers
Set sector-level TST & POS targets
Reinforce accompanied referrals for
initiation
Through regular coaching and observation during follow-up to training activities
Offer need-based clinical
mentorship for quality HTS
Identifying trends and missed
opportunities
• Work closely with District-level MOH leadership to establish clear site and sector-level targets for case identification based on historical yield
• Conduct refresher trainings with providers on HIV testing and accompanied referrals
• Hold regular data review meetings at site level to assess progress against PITC targets
Clinical Partners:
40
Male Congregate Setting Testing Strategy
• Newly funded in FY18
• 4 teams developed methodology in 4 central districts of Zambezia
• Roll-out to total of 16 districts in Zambezia in FY18
• Approach
• Venue mapping
– In Quelimane, fisherman, bicycle taxi drivers, military recruitment center, formal and informal markets
• Community-based testing
• Synergies with other prevention interventions: VMMC referrals, index case testing
Month
HIV+ Men Diagnosed
Men Tested % Yield
Among positives, % first time testers
Dec, 2017 186 1799 10% 82%
Jan, 2018 189 1969 10% 91%
Feb, 2018 254 2720 9% 91%
TOTAL 629 6488 10% 89%
41
# of Men Diagnosed Through Male Congregate Testing Promising
392
222
186
150
46 32
9 6 5 4 3 2 0
50
100
150
200
250
300
350
400
450
Other PICTMale congregateVCT Emergency VMMCCommunity IndexFacility Index TB VMMC Inpatient KP
# D
iagn
ose
d w
ith
HIV
Adult Males Diagnosed with HIV in Quelimane, Zambezia--December, 2017
42
Decision Tree: Case Identification for Adult Men
Problem Diagnosis Strategic Objective
Approach
Low case identification
for men
Increase case identification of
HIV+ men
Problem Statement/Indicator
Men not seeking health care @
facilities
Providers not screening men
sufficiently for HIV risk within high-
yield sectors
Providers not following-up
sufficiently with women for index case or partner
testing
Index coverage proxy by district; MER & New HTC
Registers
Monitoring and Partner Management
Sector-specific testing coverage by site; MER &
New HTC Registers
Optimize Facility-Based Testing (PICT & ANC
Partner Testing)
Scale-up Community-Based Index Case Testing
Male Congregate Setting Testing
43
HTC Targeting Increase in Index Case Testing
COP17 COP18
Row Labels Tests Pos Yield Distribution of Pos Tests Pos Yield
Distribution of Pos
Community IC 220,710 32,009 14.5% 8.4% 200,851 50,755 25.3% 13.7%
Mobile 159,732 11,656 7.3% 3.1% 47,658 4,603 9.7% 1.2%
Other Community 43,790 4,398 10.0% 1.2% 0.0%
Facility IC 13,796 1,570 11.4% 0.4% 31,629 10,114 32.0% 2.7%
Inpatient 85,699 18,260 21.3% 4.8% 55,875 7,743 13.9% 2.1%
Emergency 2,631,541 159,681 6.1% 43.0%
VCT 600,577 82,900 13.8% 21.7% 836,030 88,692 10.6% 23.9%
Other PICT 3,197,609 216,270 6.8% 56.7% 667,394 37,456 5.6% 10.1%
TB 39,595 9,420 23.8% 2.5% 99,268 5,025 5.1% 1.4%
VMMC 401,545 4,870 1.2% 1.3% 396,642 7,500 1.9% 2.0%
Total 4763053 381353 8.0% 100.0% 4966888 371569 7.5% 100.0%
Index Case POS Target Doubled,
16.4% of all POS
44
Focusing Targets in Areas of Highest Unmet Need
45% of all testing targets in FY19 are from the 20
districts with the highest unmet need for men
Province District Adult Male POS Maputo Matola 5,661
Sofala Beira 5,547
Manica Chimoio 3,985
Zambezia Quelimane 3,903
Cidade De Maputo Kamavota 3,189
Zambezia Mocuba 2,935
Tete Tete 2,786
Sofala Dondo 2,520
Cidade De Maputo Nlhamankulu 2,512
Gaza Chokwe 2,236
Cidade De Maputo Kampfumu 2,234
Zambezia Pebane 2,175
Zambezia Namacurra 2,001
Zambezia Nicoadala 1,988
Maputo Marracuene 1,982
Cidade De Maputo Kamaxakeni 1,898
Maputo Manhiça 1,880
Manica Manica 1,708
Nampula Moma 1,675
Cidade De Maputo Kamubukwana 1,657
Cabo Delgado Pemba 1,605
Cabo Delgado Mueda 1,500
Sofala Nhamatanda 1,488
Zambezia Maganja Da Costa 1,484
Gaza Chibuto 1,460
Cabo Delgado Muidumbe 1,413
Gaza Xai-Xai 1,402
Case identification efforts among men
in FY19 will continue to focus on districts
with the highest need
Improving Rates of Treatment Initiation Among Men
46
FY18 Q1 Treatment Performance by Partner
IP TX_NEW Q1FY18
TX_NEW FY18 Target
TX_NEW Q1FY18%
Achievement
TX_CURR Q4_FY17
TX_CURR Q1_FY18
TX_CURR FY18 Target
TX_CURR Q1FY18%
Achievement
NET_NEW (Q1FY18
vs Q4FY17)
FY18_ NET_NEW
Target
NET_NEW Q1FY18 %
Achievement
TX_CURR Growth
ICAP 13,337 47,900 28% 131,656 139,872 162,783 86% 8,216 31,127 26% 6%
FGH 11,365 60,268 19% 105,319 96,476 128,273 75% 4,011 35,808 11% 4%
ARIEL 11,996 64,726 19% 169,744 176,571 207,971 85% 6,827 38,227 18% 4%
JHPIEGO (DOD) 713 4,701 15% 11,085 11,522 13,916 83% 437 2,831 15% 4%
EGPAF 8,651 46,764 18% 129,371 133,009 165,985 80% 3,638 36,614 10% 3%
CHASS 22,316 97,731 23% 251,423 268,260 349,741 77% 3,983 85,464 5% 2%
CCS 11,252 53,087 21% 196,910 198,204 233,461 85% 1,294 36,551 4% 1%
Overall New on Treatment, Current on Treatment, Net New, and Growth in Tx_Curr by Partner
47
Most Provinces On Track to Achieve Targets for TX_NEW Target for Men
14% 16%
34%
23%
9%
21% 19%
43%
18%
35%
29%
23%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
0
1000
2000
3000
4000
5000
6000
7000
_MilitaryMozambique
Cabo Delgado Cidade DeMaputo
Gaza Inhambane Manica Maputo Nampula Niassa Sofala Tete Zambezia
Male Quarterly New on Treatment Trend (FY17 – FY18) and Target Achievement (FY18 Q1)
FY17 Q1
FY17 Q2
FY17 Q3
FY17 Q4
FY18 Q1
FY18 % Target
Main challenges are in Cabo Delgado, Inhambane, Niassa, and Military sites:
48
Decision Tree: Treatment Initiation Among Men
Problem Diagnosis Strategic Objective
Approach
Lower rates of treatment initiation
among HIV+ Men
Problem Statement/Indicator
Monitoring and Partner Management
Challenges with case identification
Lower rates of
linkage to treatment
Lack of male-
friendly services
Lower health seeking behavior
among men
Stigma/Cultural Norms
49
Linkage to Treatment Remains Lower among Men than Women in All Provinces
99% 104%
91% 90% 90%
98%
83% 79% 80%
85%
94%
79%
93%
77%
89%
71%
87%
63% 58%
67% 69% 75%
0%
20%
40%
60%
80%
100%
120%
0
2000
4000
6000
8000
10000
12000
CaboDelgado
Gaza Inhambane Manica Maputo Maputo City Nampula Niassa Sofala Tete Zambezia
Linkage Proxy (TX_NEW/HTX_POS), Females vs. Males, FY18 Q1
Linkage to Treatment Highest in Gaza, Manica, and Maputo City
50
Linkage to Treatment Increased in All Provinces in FY18 Q1
70%
75%
59%
76%
70% 75%
60%
53% 56%
61%
74%
68%
79%
93%
77%
89%
71%
87%
63%
58%
67% 69%
75% 75%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Cabo Delgado Gaza Inhambane Manica Maputo Maputo City Nampula Niassa Sofala Tete Zambezia National
Ration of TX_NEW to HTX_POS by Province, FY17 Q4 and FY18 Q1
FY17 Q4 FY18 Q1
51
Notable Improvements in Linkage to Treatment with Roll-out of T&S
0%
20%
40%
60%
80%
100%
120%
Q1FY17 Q2FY17 Q3FY17 Q4FY17 Q1FY18
Lin
kage
%
Quarterly Male Linkage by Test & Start Phase, Q1FY17 to Q1FY18
Phase 1
Phase 2
Phase 3
Phase 4
Aug 2016 Test & Start
Phase 1
March 2017 Test & Start
Phase 2
Sept 2017 Test & Start
Phase 3
52
Decision Tree: Treatment Initiation Among Men
Problem Diagnosis Strategic Objective
Approach
Lower rates of treatment initiation
among HIV+ Men
Improve ART uptake among
men Finalize and
implement national tools for linkage
tracking
Problem Statement/Indicator
Complete roll-out of T&S with same-day
clinical appointments and ART initiation <15
days
HTC_Pos (Male):
TX_NEW (male)
Monitoring and Partner Management
Challenges with case identification
Lower rates of
linkage to treatment
Lack of male-
friendly services
Lower health seeking behavior
among men
Stigma/Cultural Norms
53
National Roll-out of T&S
Aug 2016
Phase 1 T&S
• 14 highest burden districts
• Est. PLHIV: 772,000 (36% of PLHIV)
April 2017
Phase 2 T&S
• 8 high-burden districts
• Est. PLHIV: 218,000 (10% of PLHIV)
Sept 2017
Phase 3 T&S
• 37 districts
• Est. PLHIV: 548,000 (26% of PLHIV)
FY18: National Roll-out of T&S
• 96 districts
• Est. PLHIV: 585,000 (28% of PLHIV)
52% 52%
43% 40%
0%
10%
20%
30%
40%
50%
60%
0
100000
200000
300000
400000
500000
Phase 1 Phase 2 Phase 3 Phase 4
FY17 Unmet Need and ART Coverage by Test and Start Phase
Number on Treatment Unmet Need Coverage
Update on Phase 4: February
2018 Circular
Announcing T&S in all remaining Scale-up Districts
54
63%
83%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Proportion of Newly Enrolled who’s Clinical Appointment was the Same Day as their Diagnosis
a.Sept-Oct 2016 b.Oct-Nov 2016 c.Nov-Dec 2016 d.Dec-Jan 2017 e.Jan-Feb 2017
f.Feb-Mar 2017 g.Mar-Apr 2017 h.Apr-May 2017 i.May-Jun 2017 j.Jun-July 2017
k.Jul-Aug 2017 l.Aug-Sept 2017 m.Sept-Oct 2017 n.Oct-Nov 2017 o.Nov-Dec 2017
*Data from High-volume T&S Phase 1 Sites
Same Day Clinical Appointments and ART initiation within 15 days
• HTC Counselor opens clinical file in testing sector, enrolling patient in HIV care
• Patient escorted to clinical visit
• Receives first pre-ART counseling the day of diagnosis
• Referred for consented follow-up (phone call followed by home visit) if does not return to initiate ART in <15 days
55
HTC daily register: Instructions on how to fill in the clinical linkage page
Linkage monitoring For each patient
diagnosed with HIV, the testing provider records personal data and the patient's clinical follow-up plan on the clinical linkage control page
Revised MISAU HTC Register
56
Linkage Monitoring If a patient does not
reach the clinical services (is not linked within 7 days), the contact information is used to perform the active search.
HTC daily register: Instructions on how to fill in the clinical linkage page
Revised MISAU HTC Register
57
Translating Linkage work into COP18 Targeting Approach
Linkage Assumptions for COP18:
• Assumes 100% of identified positives eligible for treatment
(Test & Start)
• 4% of New on ART will be from persons previously identified
• This is based on the assumption that the final, national roll-out of T&S will be mostly completed prior to the start of COP18
• Assumes 85% linkage of positives into treatment nationally
• Consistent with improved performance trend, after pre-ART enrollments have subsided
58
Decision Tree: Treatment Initiation Among Men
Problem Diagnosis Strategic Objective
Approach
Lower rates of treatment initiation
among HIV+ Men
Improve ART uptake among
men
Problem Statement/Indicator
Monitoring and Partner Management
TX_CURR (male)
Implement male engagement package
to improve service delivery to men
Challenges with case identification
Lower rates of
linkage to treatment
Lack of male-
friendly services
Lower health seeking behavior
among men
Stigma/Cultural Norms
59
Most Provinces On Track to Achieve Targets for TX_NEW Target for Men
14% 16%
34%
23%
9%
21% 19%
43%
18%
35%
29%
23%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
0
1000
2000
3000
4000
5000
6000
7000
_MilitaryMozambique
Cabo Delgado Cidade DeMaputo
Gaza Inhambane Manica Maputo Nampula Niassa Sofala Tete Zambezia
Male Quarterly New on Treatment Trend (FY17 – FY18) and Target Achievement (FY18 Q1)
FY17 Q1
FY17 Q2
FY17 Q3
FY17 Q4
FY18 Q1
FY18 % Target
Notable Increase in Treatment Initiations in Gaza, Sofala, and Zambezia
60
Compiling Best Practices in Reaching Men
61
Male Engagement Strategy Approaches to Improve Treatment Initiation
• Comprehensive disease screening in male outreach programs, and male-focused clinics
• Extended hours in select sites Male-friendly services
• Facilitation of community dialogues (“Men-for-men”), engagement of community & religious leaders to promote changes in social norms
Promoting New Social Norms
• Expansion of family approach including provision of male-focused prevention and family planning messages to couples
Family-based care
• Mobilization of men through male champion & community leaders to improve uptake of services
Communication & Advocacy
• Utilize routine information system indicators disaggregated by gender to monitor impact of strategy on uptake of services by men
Measuring Impact
62
Targeting Male Engagement Strategy to Areas of Highest Need
Highest Burden Districts Included
Among 59 Districts
Prioritized for Male
Engagement in FY18-FY19
63
Decision Tree: Treatment Initiation Among Men
Problem Diagnosis Strategic Objective
Approach
Lower rates of treatment initiation
among HIV+ Men
Improve ART uptake among
men Finalize and
implement national tools for linkage
tracking
Problem Statement/Indicator
Complete roll-out of T&S with same-day
clinical appointments and ART initiation <15
days
HTC_Pos (Male):
TX_NEW (male)
Monitoring and Partner Management
TX_CURR (male)
Implement male engagement package
to improve service delivery to men
Challenges with case identification
Lower rates of
linkage to treatment
Lack of male-
friendly services
Lower health seeking behavior
among men
Stigma/Cultural Norms
Improving Retention and Adherence to Treatment
65
Lower Retention Among Males, Especially Young Males Nationally
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
12
-mo
nth
Ret
enti
on
(%
)
Retention Among All Persons, Adult Men, and Adolescent Men by Province, FY17
Total (all populations) Adult Men Adolescent Men (15 to 24 years)
66
Enhanced Retention Monitoring Shows Only Minimal Improvements
3-month retention remains low at 70% Most patient attrition occurs in the first 3 months of treatment
67
Viral Suppression Appears to Be Lower for Men than Women, FY17 (DISA)
Source: DISA FY17
Routine Suspected Failure Not Specified
Not suppressed
Suppressed Not
suppressed Suppressed
Not suppressed
Suppressed
Males 15+ 8,729 17,327 1,416 1,230 3,259 6,463
34% 66% 54% 46% 34% 66%
Females 15+ 25,637 57,658 2,423 2,008 7,791 19,993
31% 69% 55% 45% 28% 72%
TOTAL 40,279 78,934 4,469 3,414 13,054 28,187
34% 66% 57% 43% 32% 68%
68
Viral Load Suppression For Men Was Around 66% at FY17 (DATIM)
VL suppression rates were
lowest among children and
adolescents and increased with
age
66%
42%
50%
60% 63%
74%
69
Decision Tree: Improving Adherence & Retention among Men
Problem Diagnosis
Strategic Objective
Low retention and VL
suppression among Men
Increase retention
and adherence
among men
Problem Statement/Indicator
Poor health seeking behavior
Health care system not male-friendly
Challenges accessing services
Stigma/cultural norms lead to low patient adherence
Late initiation leads to poorer outcomes
70
Decision Tree: Improving Adherence & Retention among Men
Problem Diagnosis
Strategic Objective
Low retention and VL
suppression among Men
Increase retention
and adherence
among men
Differentiated Service Delivery
Problem Statement/Indicator
Poor health seeking behavior
Health care system not male-friendly
Challenges accessing services
Stigma/cultural norms lead to low patient adherence
Late initiation leads to poorer outcomes
Improve Psychosocial Services available to Men
Improving Quality of Services
Increased Outreach to Reduce Stigma, Address
Cultural Norms
Community Outreach to Improve Linkage to
Services
MISAU’s Five Pillars for
Improving Adherence &
Retention
71
Decision Tree: Improving Adherence & Retention among Men
Problem Diagnosis
Strategic Objective
Low retention and VL
suppression among Men
Increase retention
and adherence
among men
Differentiated Service Delivery
Problem Statement/Indicator
Poor health seeking behavior
Health care system not male-friendly
Challenges accessing services
Stigma/cultural norms lead to low patient adherence
Late initiation leads to poorer outcomes
Improving Quality of Services
Enhanced Retention Monitoring; DSD
M&E
Approach Monitoring and Partner Management
72
Improving Availability of Patient-Friendly Services
Key Differentiated Service Delivery Approaches in Mozambique
• Community Adherence and Support Groups
• 3-month drug dispensing
• Family approach
• One-stop-shop models (MCH, TB, Adolescents)
• Adherence clubs/Support groups
• Community ART distribution through mobile brigades
73
Uptake of Differentiated Service Delivery Approaches (Dec 2017)
Activity Number of Facilities
Implementing
Test and Start 712
GAACs 475
Family Approach
257
3-Month Drug Dispensing
66
% Uptake from High-Volume Test & Start Sites from 5 partners
74
COP18 Plans to Increase Uptake and Fidelity of DSD Approaches
Dissemination of MISAU tools to improve harmonization and increase uptake of approved approaches
75
Vaccination
Vitamin A
Child Growth
Monitoring
Family Planning
Pre-Natal + Post-
Partum Care
Maternal Health
Community
Mobile
Brigade
ART
New Approaches to Reach Hard-to-Reach Populations
76
Enhanced Quality Improvement Focused on Adherence & Retention
Objectives Activities Anticipated
Impact
1 Improve quality of services in facilities
nationally Expansion of National QI Strategy
Quality and friendly
services can
encourage men to
return to the
facility and be
adherent to
medication
2
Continuous staff capacitation &
mentorship to assure male-friendly
services
Revitalize use of tools for routine
for clinical mentorship
3
Identification of causes for low men
retention and adherence and plan men-
centered corrective interventions
Develop facility-based action plans
using newly incorporated
indicators on retention and VL
4
Provide oversight/support for QI
activities to assure men-centered
interventions are implemented
Joint supervision with MISAU
using standardized approach
77
Decision Tree: Improving Adherence & Retention among Men
Problem Diagnosis
Strategic Objective
Low retention and VL
suppression among Men
Increase retention
and adherence
among men
Problem Statement/Indicator
Poor health seeking behavior
Health care system not male-friendly
Challenges accessing services
Stigma/cultural norms lead to low patient adherence
Late initiation leads to poorer outcomes
Approach Monitoring and Partner Management
Improve Psychosocial Services available to Men
Increased Outreach to Reduce Stigma, Address
Cultural Norms
Community Outreach to Improve Linkage to
Services
Retention and VL suppression indicators
disaggregated by gender and age
78
Integration of Peer Support into National System
APSS Focal Person (Ministry Staff)
HEA
LTH
FA
CIL
ITY
(M
ISA
U/D
PS/
PEP
FAR
)
CO
MM
UN
ITY
SU
PP
OR
T (P
EPFA
R/G
F/C
BO
s)
Support for Linkage, Counseling & Adherence
Support, Phone Calls after Missed Visits
Lay Counselors/ Peer Educators (Clinical partners)
Peer Educators/Activists (Community partners)
Adherence Support, Supportive Home Visits,
Loss-to-Follow-up Tracing,
79
Adherence Support for Targeted Patients
1. All men with identified adherence problems (including defaulters)
2. Viral load > 1000 Copies and/or CD4<200
3. Patients with suspected treatment failure 4. All patients with positive EID results
1. All men initiating ART with high adherence risk (using stratification tool)
2. All PBFW (stratified by risk) 3. All children 0-14 years (stratified by
risk) 4. TB-HIV patients 5. Patients with other chronic severe
clinical conditions and malnutrition
Preventive/Supportive Home Visits
Facility & Community-based Peer
Support
Targeted Home-Based Psychosocial Support
80
Schedule for Targeted Home-Based Psychosocial Support
POPULATION ACTIVITY FOLLOW-UP SCHEDULE
Day 0 (ART start)
15 days
30-45 days
2 3 4 5 6 7 8 9 10 11 12
Adults Newly Initiated on ART
Counselling x x x x x x x
Supportive home visits (If
identified as high risk)
x x x x
FOLLOW UP SCHCEDULE
Adults Stable on ART
Counselling • Continues every 3 months
Adults Not Stable on ART (High VL, Poor
Adherence)
Phone Calls/ Home Visits
• Monthly visits for 3 months to reinforce adherence • Afterwards resume quarterly counseling visits at the health facility
Adults at Risk for LTFU
(Defaulters)
Phone Calls/ Home Visits
• If patient misses appointment receives a phone call within 7 days • If not reached after 3 attempts within 3 days, referred for home visit (active tracing)
• Up to 3 visits within 3 weeks to encourage return to facility
81
Community Activities to Improve Adherence & Retention among Men
Strengthened community support
encouraging men to seek and be retained
on treatment
Improve Treatment Literacy by leveraging
Key Community stakeholders and
structures
Community-level support through GAAC’s, Men and
Saving’s Groups
Improved monitoring of Community Interventions
supporting retention
82
Decision Tree: Improving Adherence & Retention among Men
Problem Diagnosis
Strategic Objective
Low retention and VL
suppression among Men
Increase retention
and adherence
among men
Differentiated Service Delivery
Problem Statement/Indicator
Poor health seeking behavior
Health care system not male-friendly
Challenges accessing services
Stigma/cultural norms lead to low patient adherence
Late initiation leads to poorer outcomes
Improve Psychosocial Services available to Men
Improving Quality of Services
Increased Outreach to Reduce Stigma, Address
Cultural Norms
Community Outreach to Improve Linkage to
Services
Enhanced Retention Monitoring; DSD
M&E
Retention and VL suppression indicators
disaggregated by gender and age
Targets & Budget
84
Summary of Targets
General Targeting Approach:
• Aimed to accelerate treatment initiation to achieve 20% higher TX_NEW in COP18 as compared to COP17
• Targeting for highest growth in locations with most unmet need
• Focus on improving retention to achieve 90% retention among new on treatment and 95% retention among those on treatment >12 months
Scale-up Saturation Districts
FY17 Coverage Targeted Growth:
>90% 10% increase per year
71-90% 15% increase per year
61-70% 25% increase per year
51-60% 30% increase per year
Scale-up Aggressive Districts
51-60% 30% increase per year
41-50% 35% increase per year
21-40% 40% increase per year
<20% 50% increase per year
Sustained Districts
10% per year
Attained Districts
5% increase per year
85
Continued Geographic Focus in Areas of Highest Need
354023 409091 480109 528569
507559 699404
913867 1103587
117443
135889
168877
184615
0
200000
400000
600000
800000
1000000
1200000
1400000
1600000
1800000
2000000
FY17 TX_CURR FY18 TX_CURR TargetFY19 Target TX_CURRFY20 Target TX_CURRN
um
ber
of
PLH
IV
Increase in Current on Treatment by District Prioritization, FY17 to FY20
Attained ScaleUp Sat ScaleUp Agg Sustained
86
Aggressive Growth Planned in All Provinces
0
100000
200000
300000
400000
500000
600000
Cabo Delgado Gaza Inhambane Manica Maputo Nampula Niassa Sofala Tete Zambezia
Nu
mb
er o
f P
LHIV
Projected Treatment Trend by Province FY17 to FY20 and Est. PLHIV (FY19)
FY17 TX_CURR FY18 TX_CURR Target FY19 Target TX_CURR FY20 Target TX_CURR Estimated # of PLHIV, end of FY19
0%
20%
40%
60%
80%
100%
120%
Cabo Delgado Gaza Inhambane Manica Maputo Nampula Niassa Sofala Tete Zambezia Grand Total
Co
vera
ge
Projected ART Coverage Trend by Province, FY17 to FY20
FY17 Coverage FY18 Coverage FY19 Coverage FY20 Coverage
87
Targeting Growth Towards National 90-90-90 Targets in FY20
46%
58%
72%
83%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
500000
1000000
1500000
2000000
2500000
FY17 FY18 Expected FY19 Target FY20 Target
Current on Treatment, Unmet Need, and Covearge, FY17 to FY20
Current on Treatment Unmet Need Coverage
88
Care and Treatment Budget Highlights
89
Key Approaches to Achieve Care and Treatment Objectives at the Site Level
90
Key Approaches to Achieve Care and Treatment Objectives at the Above-Site Level
91
Summary on Strategies to Reach Men in COP18
Core Strategies to Improve Identification, Uptake, and Adherence to Treatment among Men:
• Scale-up proven linkage strategies
• Ensure broad-scale dissemination of MISAU-approved DSD strategies
• Strengthen implementation of MISAU-guidelines on pyscho-social support
• Promote improved community-facility linkages
• Maximize efficiency of investments to maintain and scale-up core and cut-back on low-impact activities
92
Obrigada!
Questions?